Racial/Ethnic Disparities in End-of-Life Care in a Medicaid Population

This study focused on a cohort of nonelderly Medicaid beneficiaries with stage IV breast or colorectal cancer who resided in New Jersey.

A retrospective
study of nonelderly New Jersey Medicaid enrollees with advanced cancer showed
higher rates of aggressive end-of-life care for non-Hispanic black patients
compared with other racial/ethnic groups. These findings were published in JCO Oncology Practice.

Racial and ethnic disparities regarding the type of end of life care received have been reported for patients with advanced cancer enrolled in Medicare, and include a higher likelihood of aggressive treatment in the last few weeks of life for patients in racial/ethnic minority groups. However, less is known about whether such disparities exist for patients with advanced cancer who are nonelderly Medicaid beneficiaries.

In this study, the New
Jersey State Cancer Registry (NJSCR)–Medicaid claims linked database was used to explore end-of-life
care in a cohort of patients with advanced breast or advanced colorectal cancer
who resided in New Jersey and were aged 21 to 64 years with stage IV disease at
the time of first primary cancer diagnosis which occurred between 2011 and 2015.
All included patients were continuously enrolled in Medicaid for more than 60
days prior to death with a date of death occurring before February 1, 2016.

Measures
of aggressive end-of-life care included more than 1 inpatient hospitalization,
more than 1 emergency department visit, and any intensive care unit (ICU)
admission within 30 days prior to death, receipt of chemotherapy within 14 days
of death, as well as a composite measure that combined those 4 criteria. Data
regarding whether patients had been enrolled in a hospice program at any time
prior to death and in the last 3 days of life were also collected.

The
median survival of the 349 patients included in the study was 14 months. Nearly
half of patients were enrolled in Medicaid for less than 1 month in the year
prior to cancer diagnosis, and self-reported race/ethnicity was non-Hispanic
white, non-Hispanic black, Hispanic, and non-Hispanic Asian Pacific Islander
for 44%, 33%, 18%, and 5% of patients, respectively.

At
least one measure of aggressive end of life care was observed for 73% of non-Hispanic
black patients, 60% of non-Hispanic white patients, 59% of non-Hispanic Asian
Pacific Islanders, and 48% of Hispanic patients. Following adjustments for clinical
and sociodemographic characteristics, and using non-Hispanic white patients as
a comparator group, non-Hispanic black patients were significantly more likely
to have received any type of aggressive end-of-life care (odds ratio [OR],
1.87; 95% CI, 1.07-3.26), and to have undergone more than 1 hospitalization (OR,
1.98; 95% CI, 1.13-3.47), and more than 1 emergency department visit (OR, 1.79;
95% CI, 1.05-3.06) within 30 days of death.

Regarding
these findings, the study authors pointed out that although “all patients in
our study were low-income Medicaid beneficiaries, black patients were twice as likely to receive
aggressive [end-of-life] care compared with [non-Hispanic] white patients.”

Rates
of any enrollment in hospice care were 42% for non-Hispanic white patients, 43%
for non-Hispanic black patients, 35% for Hispanic patients, and 29% for non-Hispanic
Asian Pacific Islanders, respectively; there was no significant difference by
race/ethnicity group, and rates of hospice enrollment within 3 days of death
were below 20% in all groups.

“Strategies
to increase awareness of community preferences for [end of life] care at the
provider, health system, and policy levels, as well as strengthening
communication strategies between clinicians and patients, are needed to achieve
optimal [end-of-life] care for low-income and vulnerable populations,” the
study authors commented in their concluding remarks.

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